THE WORLD BANK

ETHIOPIAREPROducTIvE HealtH

GLANcEat a

April 2011

MdG Target 5A: Reduce by Three-quarters, between 1990 and 2015, the Maternal Mortality RatioEthiopia has been making progress over the past two decades on maternal health but it is not on track to achieve its 2015 targets.5

Figure 1 n Maternal mortality ratio 1990–2008 and 2015 target

990920

750

560470

250

0

200

400

600

800

1000

1200

1990 1995 2000 2005 2008 2015

MDGTarget

Source: 2010 WHO/UNICEF/UNFPA/World Bank MMR report.

country contextIn recent years, Ethiopia has been one of the fastest growing economies in Africa with robust growth performance and considerable development gains from 2003 to 2007. Over the past two decades, there has been significant progress in key human development indicators: primary school enrollments have quadrupled, child mortality has almost been cut in half, and the number of people with access to clean water has more than doubled. More recently, poverty reduction has ac-celerated. The poverty headcount, which stood at 46 percent in 1999 and 2000, fell to 39 percent in 2004/5.1 Two-fifths of the population still subsists on less than US $1.25 per day.2

Ethiopia’s large share of youth population (44 percent of the country population is younger than 15 years old2) pro-vides a window of opportunity for high growth and poverty reduction—the demographic dividend. For this opportu-nity to result in accelerated growth, the government needs to invest more in the human capital formation of its youth. This is especially important in a context of decelerated growth rate arising from the global recession.

Gender equality and women’s empowerment are im-portant for improving reproductive health. Higher levels of women’s autonomy, education, wages, and labor mar-ket participation are associated with improved reproduc-tive health outcomes.3 In Ethiopia, the literacy rate among females ages 15 and above is 23 percent.2 Fewer girls are enrolled in secondary schools compared to boys with a 72 percent ratio of female to male secondary enrollment.2

Four-fifths of adult women participate in the labor force 2 that mostly involves work in agriculture. Gender inequali-ties are reflected in the country’s human development rank-ing; Ethiopia ranks 149 of 157 countries in the Gender-related Development Index.4

Greater human capital for women will not translate into greater reproductive choice if women lack access to repro-ductive health services. It is thus important to ensure that health systems provide a basic package of reproductive health services, including family planning.3

World Bank support for Health in EthiopiaThe Bank’s Country Assistance Strategy Progress Report under preparation (P118836) was approved by the Bank’s Executive Board on November 4, 2010.

current Project:P106228 ET-Ethiopia Nutrition SIL (FY08) ($30m)

Pipeline Project: P124821 maET: Nutrition coordination capacity dev Approval date 1/5/2011P123531 Ethiopia Health MDG support operation Appraisal date 5/24/2011

Previous health project: P098031 ET-Multi-Sectoral HIV/AIDS II (FY07)

Ethiopia: MdG 5 status

MdG 5A indicators

Maternal Mortality Ratio (maternal deaths per 100,000 live births) UN estimatea

470

Births attended by skilled health personnel (percent) 18

MdG 5B indicators

Contraceptive Prevalence Rate (percent) 32

Adolescent Fertility Rate (births per 1,000 women ages 15–19) 104

Antenatal care with health personnel (percent) 71.4

Unmet need for family planning (percent) 33.8

Source: Table compiled from multiple sourcesaThe 2005 DHS estimated maternal mortality ratio at 673. Data collection for DHS 2010/11 is underway..

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

n Key challenges

High FertilityFertility remains high. Total fertility rate (TFR) fell slightly from 6.4 births per woman in 1990 to 5.4 in 2005.6 TFR is very high (over 6) among women in the lower three wealth quintiles while it is 3.2 among women in the highest quintile (Figure 2).6

Figure 2 n Total fertility rate by wealth quintile

0

321

54

67

5.4 overall

Poorest Second Middle Fourth Richest

6.6 6.0 5.7

3.2

6.2

Source: DHS Final Report, Ethiopia 2005

Disparities exist between women in rural areas at 6.0 births per woman compared to 2.4 for those in urban areas, and vary by education levels at 6.1 births per woman with no education, and 2 with secondary education or higher.

Adolescent fertility rate is high (104 reported births per 1,000 women aged 15–19 years) affecting not only young women and their children’s health but also their long-term education and employment prospects. Births to women aged 15–19 years old have the highest risk of infant and child mortality as well as a higher risk of morbidity and mortality for the young mother.3, 7

Early childbearing is more frequent among the poor. While 48 percent of the poorest 20–24 years old women have had a child before reaching 18, only 23 percent of their richer counterparts did (Figure 3). Furthermore, reduction in early childbearing mostly has taken place among the rich where younger cohorts of girls are less likely than older cohorts to have a child early in life.

Figure 3. Percent women who have had a child before age 18 years by age group and wealth quintile

PoorestPoorest

Poorest

Richest

Richest

Richest

>34 years20–24 years 25–34 years0%

10%20%30%40%50%60%

Source: DHS Final Report, Ethiopia 2005 (author’s calculation)

Over a tenth of women use contraception. Current use of con-traception among married women is 14 percent.6 Injectables are the most commonly used method among married women at 10 percent followed by the pill at 3 percent. Use of long-term meth-ods such as intrauterine device and implants are negligible. There

are socioeconomic differences in the use of modern contraception among women: it is high among women with secondary educa-tion or higher (46 percent), urban women (42 percent) and 34 percent among women in the highest wealth quintile (Figure 4).

Figure 4 n use of contraceptives among married women by wealth quintile

0

0.2 0.1

4.0 6.511.6

0.415.2

0.320

10

30

40

14.7 Overall (All methods)

Poorest Second Middle Fourth

33.73.3

Richest

Modern Methods Traditional Methods

Source: DHS Final Report, Ethiopia 2005

Unmet need for contraception is high at 34 percent indi-cating that women may not be achieving their desired fam-ily size.8 The abortion law reform, expanded in 2005, now gives women more options in seeking safe abortion services. Still, 6 in 10 abortions in Ethiopia are unsafe.9

Opposition to use (24 percent) and wanting more children (17 percent) are the predominant reasons women do not in-tend to use modern contraceptives in future. Further, 13 per-cent cited fear of side effects or health concerns.6 Cost and ac-cess are lesser concerns, indicating further need to strengthen demand for family planning services.

Poor Pregnancy OutcomesMore pregnant women use antenatal care than delivery with health personnel.. Over two-thirds of pregnant women received antenatal care with 31 percent having received the recommend four visits. However, only 16 percent of the deliveries were at-tended by skilled health personnel.10

While 27 percent of women in the wealthiest quintile delivered with skilled health personnel, less than a percent of women in the poorest quintile obtained such assistance (Figure 5). Additionally,

Figure 5 n Birth assisted by skilled health personnel (percentage) by wealth quintile

Poorest Second Middle Fourth

0.7 1.3 1.94.5

26.6

Richest

5.7% overall

0

5

10

15

20

25

30

DHS Final Report, Ethiopia 2005

two percent of women with no education delivered with skilled health personnel as compared to 58 percent of women with sec-ondary education or higher. Further, 63 percent of all pregnant women are anaemic (defined as haemoglobin < 110g/L) increas-ing their risk of preterm delivery, low birth weight babies, still-birth and newborn death.11

Two-thirds or more women who indicated problems in ac-cessing health care cited concerns regarding concerns that no provider is available, inability to afford the services, long dis-tance, transport difficulties, or no other person to complete household chores (Table 1).6

Human resources for maternal health are limited with only 0.02 physicians per 1,000 population but nurses and midwives are slightly more common, at 0.24 per 1,000 population.2

The high maternal mortality ratio at 470 maternal deaths per 100,000 live births indicates that access to and quality of emer-gency obstetric and neonatal care (EmONC) remains a challenge.5

The 2008 EmONC assessment revealed 51 percent of hospi-tals provide comprehensive EmONC and only 9 provide basic EmONC services.12

STIs/HIv/AIdS is public health concernHIV prevalence if relatively low but women are one of the most vulnerable groups. The adult population that has HIV is 1.4 per-cent in 2005 but the prevalence among females is significantly high-er than among males (1.9 percent and 0.9 percent, respectively).6

Knowledge of mother to child prevention methods is limit-ed. A fifth of women know that HIV can be transmitted through breast milk and that the likelihood of passing HIV from mother to child can be reduced by drugs.6

There is a large knowledge-behavior gap regarding condom use for HIV prevention. While 45 percent of young women are aware that using a condom in every intercourse prevents HIV, only 2 percent of them report having used condom at last inter-course (Figure 6).

development partners support for reproductive health in EthiopiauSAId: Integrated health care; health care system capacity building

SIdA: Reducing child and maternal mortality

cIdA: Technical assistance and monitoring for MCH

GIZ: Health center development

WHO: HIV/AIDS; making pregnancy safer; women’s health

uNFPA: Integrated approach to sexual and reproductive health and rights

uNIcEF: Campaign for vulnerable children – HIV/AIDS

Marie Stopes: Family planning; abortion; post-abortion care; HIV/STIs; male circumcision; maternal health

FHI: Increasing contraceptive use and lowering STIs

IPAS: Expand access to high quality abortion services

Engender Health: HIV/AIDS; reproductive health care; contraceptives; gender norms; combating early marriage and adolescent pregnancy

IntraHealth International: Community-based approaches to maternal and child health and HIV/AIDS services

IPPF: Family planning; abortion care; MCH; STIs; HIV/AIDS

Pathfinder International: Integrated services for FP, MNH, and HIV/AIDS

Technical notes:Improving Reproductive Health (RH) outcomes, as outlined in the RHAP, includes addressing high fertility, reducing unmet demand for contraception, improving pregnancy outcomes, and reducing STIs.

The RHAP has identified 57 focus countries based on poor reproductive health outcomes, high maternal mortality, high fertility and weak health systems. Specifically, the RHAP identifies high priority countries as those where the MMR is higher than 220/100,000 live births and TFR is greater than 3.These countries are also a sub-group of the Countdown to 2015 countries. Details of the RHAP are available at www.worldbank.org/population.

The Gender-related Development Index is a composite index developed by the UNDP that measures human development in the same dimensions as the HDI while adjusting for gender inequality. Its coverage is limited to 157 countries and areas for which the HDI rank was recalculated.

Figure 6 n Knowledge behavior gap in HIv prevention among young women

15–19 years 20–24 years

Knowledge Condom use at last sex

0%5%

10%15%20%25%30%35%40%45%50%

Source: DHS Final Report, Ethiopia 2005 (author’s calculation)Table 1 n Barriers in accessing health care (women age 15–49)

Reason %

At least one problem accessing health care 95.7

Concern no provider available 80.5

Getting money for treatment 75.6

Concern no female provider available 72.5

Having to take transport 71.6

Concern there may be no one to complete household chores 69.3

Distance to health facility 67.7

Not wanting to go alone 61.4

Getting permission to go for treatment 34.5

Source: DHS final report, Ethiopia 2005

n Key Actions to Improve RH Outcomes

Strengthen gender equality• The government has enacted guidelines to mainstream gender

in all sectors including health to ensure and promote gender equality and empowerment, enhancing equal opportunities in the participation of social and economic development under-takings and increasing utilization of health service by women.

Reducing high fertility• Address the issue of opposition to contraceptive use by promot-

ing the benefits of small family size. Increase family planning awareness and utilization through involvement of community members particularly men, through regular media campaigns. Enlist community leaders and women’s groups and emphasize community-based distribution.

• Promote the use of ALL modern contraceptive methods, in-cluding long-term methods, through proper counseling which may entail training/re-training health care personnel. Ensure the availability of at least three family planning options for all households.

• Strengthen post-abortion care and link it with family planning services.

Reducing maternal morbidity and mortality• Make available quality antenatal care, prioritizing the poor and

those in harder to reach rural areas. During antenatal care,

educate pregnant women about the importance of delivery with a skilled health personnel and getting postnatal check. Encourage and promote community participation in the care for pregnant women and their children.

• Promote institutional delivery through provision of maternal services free of charge in public facilities.

• Strengthen referral system for maternal health services.

• Scale-up of basic and comprehensive EmONC services.

• Increase the rate of births attended by skilled attendant by scal-ing up training programs for health officers, midwives, and emergency surgeons.

Reducing STIs/HIv/AIdS• Strengthen knowledge and skills of health personnel so that

they are able to accurately inform and counsel adolescents and youth on vulnerability to HIV/AIDS/STIs.

• Educate youth and raise awareness in the greater community to increase knowledge of HIV/AIDS and STI risks, prevention, and treatment options, and to reduce stigma.

• Include PMTCT as part of routine antenatal care and make an-tiretroviral drugs available to women who need them.

correspondence details

This profile was prepared by the World Bank (HDNHE, PRMGE, and AFTHE) and Management Science for Health (MSH). For more information contact, Samuel Mills, Tel: 202 473 9100, email: smills@worldbank.org. This report is available on the following website: www.worldbank.org/population.

References: 1. World Bank Ethiopia Country Brief, available at http://go.worldbank.

org/WA1RL12OL0. 2. World Bank. 2010. World Development Indicators. Washington DC. 3. World Bank, Engendering Development: Through Gender Equality

in Rights, Resources, and Voice. 2001. 4. Gender-related development index. Available at http://hdr.undp.org/

en/media/HDR_20072008_GDI.pdf. 5. Trends in Maternal Mortality: 1990–2008: Estimates developed by

WHO, UNICEF, UNFPA, and the World Bank 6. Central Statistical Agency [Ethiopia] and ORC Macro. 2006. Ethiopia

Demographic and Health Survey 2005. 7. WHO 2011. Making Pregnancy Safer: Adolescent Pregnancy.

Geneva: WHO. http://www.who.int/making_pregnancy_safer/top-ics/adolescent_pregnancy/en/index.html.

8. Samuel Mills, Eduard Bos, and Emi Suzuki. Unmet need for contra-ception. Human Development Network, World Bank. http://www.worldbank.org/hnppublications.

9. Guttmacher Institute. Facts on Unintended Pregnancy and Abortion in Ethiopia. April 2010. http://www.guttmacher.org/pubs/FB-UP-Ethiopia.pdf.

10. Annual performance report Federal Ministry of Health 2009/10. 11. Worldwide prevalence of anaemia 1993–2005: WHO global da-

tabase on anaemia/Edited by Bruno de Benoist, Erin McLean, Ines Egli and Mary Cogswell. http://whqlibdoc.who.int/publica-tions/2008/9789241596657_eng.pdf.

12. Ethiopia national baseline assessment for emergency obstetric care, 2008.

ETHIOPIA REPROducTIvE HEALTH AcTION PLAN INdIcATORS

Indicator Year Level Indicator Year Level

Total fertility rate (births per woman ages 15–49) 2005 5.4 Population, total (million) 2007 73.7

Adolescent fertility rate (births per 1,000 women ages 15–19) 2005 104 Population growth (annual %) 2008 2.6

Contraceptive prevalence (% of married women ages 15–49) 2010 32 Population ages 0–14 (% of total) 2008 45.0

Unmet need for contraceptives (%) 2005 33.8 Population ages 15–64 (% of total) 2008 51.6

Median age at first birth (years) from DHS — — Population ages 65 and above (% of total) 2008 3.2

Median age at marriage (years) 2005 16.5 Age dependency ratio (% of working-age population) 2008 88.7

Mean ideal number of children for all women — — Urban population (% of total) 2008 17.0

Antenatal care with health personnel (%) 2010 71.4 Mean size of households 2005 5

Births attended by skilled health personnel (%) 2005 5.7 GNI per capita, Atlas method (current US$) 2008 280

Proportion of pregnant women with hemoglobin <110 g/L 2008 62.7 GDP per capita (current US$) 2008 317

Maternal mortality ratio (maternal deaths/100,000 live births) 1990 990 GDP growth (annual %) 2008 11.3

Maternal mortality ratio (maternal deaths/100,000 live births) 1995 920 Population living below US$1.25 per day 2005 39

Maternal mortality ratio (maternal deaths/100,000 live births) 2000 750 Labor force participation rate, female (% of female population ages 15–64) 2008 80.8

Maternal mortality ratio (maternal deaths/100,000 live births) 2005 560 Literacy rate, adult female (% of females ages 15 and above) 2004 22.8

Maternal mortality ratio (maternal deaths/100,000 live births) 2008 470 Total enrollment, primary (% net) 2008 79

Maternal mortality ratio (maternal deaths/100,000 live births) target 2015 250 Ratio of female to male primary enrollment (%) 2008 89.4

Infant mortality rate (per 1,000 live births) 2008 69 Ratio of female to male secondary enrollment (%) 2008 72.3

Newborns protected against tetanus (%) 2008 84 Gender Development Index (GDI) 2008 149

DPT3 immunization coverage (% by age 1) 2010 86 Health expenditure, total (% of GDP) 2007 3.8

Pregnant women living with HIV who received antiretroviral drugs (%) 2010 8.1 Health expenditure, public (% of GDP) 2007 2.2

Prevalence of HIV, total (% of population ages 15–49) 2007 2.1 Health expenditure per capita (current US$) 2007 9.2

Female adults with HIV (% of population ages 15+ with HIV) 2007 59.6 Physicians (per 1,000 population) 2010 0.029

Prevalence of HIV, female (% ages 15–24) 2007 1.5 Nurses and midwives (per 1,000 population) 2010 0.291

National policies and strategies that have influenced Reproductive health• Enactment of the National Health policy in 1993 that stipulates delivery of health care services in a decentralized and equitable manner

• The development and implementation the of National Reproductive Health Strategy 2006–2015

• Introduction of abortion guidelines in 2006

• The launching of the accelerated training of health officers, initiation of the Masters program on Emergency surgery and obstetrics for health officers and provision of a one month in-service training on clean and safe delivery for health extension workers include the efforts being undertaken to tackle the HRH constraints.

• The Government has introduced a guideline to allow women to receive free maternal health services.

• The launching of campaign on Accelerated Reduction of Maternal and newborn death led by Africa Union

• Reproductive health strategy for adolescents and youth is being finalized

Indicator Survey Year Poorest Second Middle Fourth Richest TotalPoorest-Richest

differencePoorest/Richest

Ratio

Total fertility rate DHS 2005 6.6 6.0 6.2 5.7 3.2 5.4 3.4 2.1

Current use of contraception (Modern method) DHS 2005 4.0 6.5 11.6 15.2 33.7 13.9 –29.7 0.1

Current use of contraception (Any method) DHS 2005 4.2 6.6 12.0 15.5 37.0 14.7 –32.8 0.1

Unmet need for family planning (Total) DHS 2005 33.1 37.9 36.8 36.2 24.1 33.8 9.0 1.4

Births attended by skilled health personnel (percent)

DHS 2005 0.7 1.3 1.9 4.5 26.6 5.7 –25.9 0.03